Dr. Adil Rais , (PhD Scholar)Department of Panchakarma
Institute for Post Graduate Teaching & Research in Ayurveda
Management of Avascular Necrosis through Panchakarma : A Case study
Avascular necrosis (AVN), alsocalled osteonecrosis, boneinfarction, aseptic necrosis, and ischemicbone necrosis, is cellular death of bonecomponents due to interruption ofthe blood supply.
Clinical AVN most commonly affects theends (epiphysis) of long bones such asthe femur.
Other common sites include the humerus, knees, shoulders, ankles and the jaws. Major Symptoms include pain and restricted movements.
INTRODUCTION
•Main cause is injury to the joint.
•No universally satisfactory therapyhas been developed, even for earlydisease.
•Metallic implant is one of theoptions but higher cost makes it nonfeasible for most.
•Patients having a higher level of damage to bone tissue orpresenting in higher grades of AVN have a poor prognosis.
A male subject aged about 35 years, enrolled at the OPD of department of Panchakarma, IPGT &RA, Jamnagar with chief complaints:
•Pain at bilateral hip joint since four months.
•Restricted movements at bilateral hip joint.
•Difficulty in walking and standing from sitting position.
•Difficulty in forward bending since same duration.
•History of jerk at hip joint four months back while lifting heavy weight.
Past history of patient included history of mild facialweakness (palsy) about one and a half years back for whichhe underwent allopathic treatment (Wysolone) and gotsignificant relief.
He had habit of occasional drinking of Alcohol about twiceor thrice a weak since past ten years.
Agni: Patient was having mild Agnimandya (decreased digestion andreduced appetite)
Koshtha: Krura koshtha, history of irregular bowel habits was presentwith usually hard stools and a frequency of 1 in one or two days.
Bala: Madhyama balaPrakriti: KaphaVataja
Predominant Dosha in the disease was Vata in association with Pittaand KaphaThere was a history of sudden jerk which may be responsible for localinflammation, thus vitiating Pitta Dosha.Avarana of Kapha and Meda may also be considered to play animportant role in the manifestation of Avaranajanya symptoms likestiffness.Dushya : Rakta , Asthi and Majja dhatus
PAIN
DIFFICULTY IN WALKING
STIFFNESS
VAS
RANGE OF MOVEMENT
SUBJECTIVE CRITERIA
OBJECTIVE CRITERIA
ASSESSMENT CRITERIA
INVESTIGATIONS
MRI
Avascular necrosis of B/L femur with
minimal joint effusion
(AVN Stage II)
The lesion involve from 9 o’ clock to
4 o’ clock on sagittal
images No evident subchondralcollapse or secondary
degenerative osteoarthritis on present
scan
Procedure Duration Drugs used Dose
Rukshana
(Udwartana)
5 days •Triphala Churna
•Yava Churna
200 gms Triphala Churna
50 grams Yava Churna
Snehapana 5 days •Goghrita 1st day-30 ml
2nd day-60 ml
3rd day-100 ml
4th day-140 ml
5th day-170 ml
Virechana •Nimba amritadi Erandataila
• Triphala kwatha
•60ml
•200ml
Basti 8 days •Tikta Ksheera Basti 500-600ml
Plan of treatment
Contents of Basti Quantity
Makshika (Honey) 50 ml
Saindhava
Lavana(Rock Salt)
5 gm
Ghrita 100 ml
Kalka (Paste prepared
from guduchi and
yashtimadhu churna)
25 gms
Kwatha (Decoction of
Guduchi and
Erandamoola)
300 ml – 400 ml
Milk 100 ml
Observations
Features BT AfterUdwartana
AfterVirechana
After Basti
Right Left Right Left Right Left Right Left
Pain at hipjoint
3 3 3 3 1 1 1 1
Stiffness 4 4 2 2 1 1 1 1
Difficulty inwalking
4 4 3 3 1 1 1 1
• Body Weight changes during treatment
• Changes in VA scale during treatment
BT AfterUdwartana
AfterVirechana
After Basti
Weight (kg) 90 87 84 83
BT After udwartana After Virechana After Basti
Right Left Right Left Right Left Right Left
3 3 2 2 1 1 1 1
• Changes in Range of movements at hip joint
RIGHT LEFT
BT AfterVirechana
After Basti BT AfterVirechana
After Basti
Flexion 44o 59 o 59 o 34 o 56 o 56 o
Extension 29 o 32 o 34 o 29 o 32 o 30 o
Abduction 31 o 35 o 36 o 27 o 32 o 32 o
Discussion
Udwartana was planned for externalRukshana owing to kapha and medainvolvement.Yava and triphala churna udwartanasaid to dissolve twak gata kleda kaphaand meda.
Reduction observed in stiffness aftercompletion of Udwartana.
•2kg weight loss with a sense of lightness was present.
•Avascular necrosis of hip joint developsbasically due to obstruction of small bloodvessels supplying to femoral head.
•Dhatu sthairya is provided by Virechana.
•Said to improve blood circulation.
•Raktadhatu dushti (srotorodha) is the prime cause leading toasthi dhatu kshaya in the hip joint therefore Virechana wasplanned.
Virechana
Virechana..
•History of steroid intake was present, so detoxification wasrequired.
•Snigdha Virechana was planned owing to vata predominantcondition.
•Tikta drugs present in it like Nimba, Amrita ,Patola, Kantakari,etc. tend to directly nourish Asthidhatu .
•Eranda taila is said to be “Vataharanam”.
Basti
•This is a condition which can be correlated with Asthimajja gatavata and asthi majja dhatu kshaya.
•Involvement of vata as the main dosha in the pathogenesis of thedisease leading to asthimajja kshaya as an end result ofconsequences.
•Therefore basti was planned as the mainstay of the treatment.
• It pacifies vata and said to act directly on asthi and majjadhatu.
Guduchi and Yashtimadhu used inkalka and honey are placed in Asthisandhaniya mahakashaya by AcharyaCharaka.
Guduchi said to have one of thefinest rasayanas , known to preventageing of the tissues and degenerativechanges in all the tissues was themain drug of Basti kwatha.Also said to be Rakta prasadaka
Erandamoola was used due to itsVatashamaka property.
•Approximately 7 kg weight loss was present aftercomplete treatment.
•Improvement in range of motion owes to thesignificant relief in the stiffness and pain and thelightness produced thereafter.
•Marked change was observed in Abduction, Flexionand Extension range of movements at hip joint,bilaterally.
Before treatment
Before treatment
After Virechana
After virechana
After Basti
After basti
Confession statement
Conclusion
Necrosis is a condition wherein cellular death occursthus the aim was to check the progression of the diseaseto bring about symptomatic relief in the subject.
Udwartana, Virechana and Basti provided marked relieffrom pain, tenderness, general debility and improvementin the gait.
This was a pilot case study to evaluate the efficacy ofPanchakarma in the management of AVN.
The results produced were encouraging enough to conductthis particular study on a larger number of samples anddraw more concrete conclusions.
Early diagnosis is the key for better prognosis
Awareness should be created for role of Panchakarama ininitial stages of the disease to check the progression.